Rabeya Fatima  ( Ameen Medical and Dental Center )
Khadijah Abid  ( College of Physicians and Surgeons Pakistan )
Nabeel Naeem Baig  ( College of Physicians and Surgeons Pakistan )
Syeda Batool Ahsan  ( Saifee Hospital, Karachi )

Objective: To determine the association between cheek-biting and depression in patients visiting dental clinics for routine check-up.
Methods: The case-control study was conducted at Ameen Medical and Dental Centre, Karachi, from July 2016 to January 2017, and comprised patients coming for routine dental check-up with complaint of pain and burning in oral cavity. The subjects were divided into two equal groups of cases with cheek-biting and controls without cheekbiting. Data was collected with the help of a self-administered questionnaire and depression was assessed using the Patient Health Questionnaire-9scale. Those with score>19 were labelled as depressed. Data was analysed using Stata23.
Results: There were 70 subjects in two groups of 35(50%) cases and as many controls. The mean age for the cases was 32.86}12.68 years and for the controls it was 34.23}14.47 years. Among the cases, there were 23(65.7%) females and there were 19(54.3%) among the control. Multivariate logistic regression showed depression was significantly associated with cheek-biting (p<0.05).
Conclusion: Depression and cheek-biting were found to be significantly associated.
Keywords: Cheek-biting, Depression, Parafunction, Dental visits. (JPMA 69: 49; 2019)

Introduction :

Morsicatiobuccarum, also known as cheek-biting, is a condition characterised by chronic irritation or injury to the buccal mucosa, caused by repetitive chewing, biting or nibbling.¹ These lesions are often observed in people who are under stress or with psychogenic background.² Biting of oral mucosa is seen in 750 per million persons.³ In a Mexican dental school clinic of 23,785 patients, cheek-biting lesions were found to be the fifth most common oral mucosal finding with a prevalence of 21.7 cases per 1000 patients.⁴ Depression is a potential risk factor for impaired oral health status. Studies⁵ 6 suggested depression as a risk for temporomandibular joint dysfunction (TMD) by
influencing the association between pain and motor activity; and there is evidence that TMD and pain might have a negative effect on chewing ability. TMD in children and adolescents is prevalent with pain as a common component, and has a co-morbidity with psychosocial problems such as stress, depression, anxiety as well as somatic complaints.⁷ In TMD cases cheek-biting was the second most common para-function affecting 15% of the patients and depression was prevalent in 57% of the patients.⁸ The prevalence of cheek-biting is more in children and females.¹ In a study the prevalence of cheek-biting among 314 children was 60.51%, but headaches showed statistical significance with cheek-biting (p<0.05).⁹ A case report of a10-year old boy showed history of cheek-biting was associated with major depressive disorder.¹ In another study conducted in Saudi Arabia, headache was prevalent in 33% patients, and among the oral parafunctions, cheek-biting was the most prevalent 41%.¹⁰ There is no local data available in this regards. The current study was planned to explore the association between cheek-biting and depression.

Subjects and Methods

The case-control study was conducted at Ameen Medical and Dental Centre, Karachi, from July 2016 to January 2017, and comprised patients of either gender aged 16-65 years coming for routine dental check-up with complaint of pain and burning in oral cavity. Approval was obtained from the institutional ethics board. Sample size was calculated using OpenEpi online sample size calculator,¹¹ taking prevalence of buccal mucosa(cheek-biting) among general population as 49.1%¹² and prevalence of cheekbiting among psychiatric patients as 3%.¹³ Power of test was set at 90%. The calculated sample size was 21 cases and 21 controls. Subjects were enrolled using nonprobability consecutive sampling technique. Written informed consent was taken from all the subjects who were divided into two equal groups of cases and controls. Cases were patients presenting with ulcer on the buccal mucosa, specifically on the 1st, 2nd and 3rd molar region either unilateral or bilateral assessed clinically. Controls were patients presenting without ulcer on the buccal mucosa. Patients with obesity, pregnancy, previous dental treatment, those taking pan/gutka and with history of smoking or alcohol intake were excluded from both the groups. Depression was assessed using the Patient Health Questionnaire-9 (PHQ-9) scale. Those with score>19 were labelled as depressed. The Urdu version of the questionnaire¹⁴ were calculated. The variables associated with cases/controls in univariate logistic regression models with p<0.25 were included in a single multivariate logistic regression model. OR >1 was considered significant.

Results

There were 70 subjects in two groups of 35(50%) cases and as many controls. The mean age for the cases was 32.86 }12.68 years and for the controls it was 34.23}14.47 years. Among the cases, there were 23(65.7%) females and there were 19(54.3%) among the controls, Besides, 20(57.1%) cases and 21(60%) controls were married; 33(94.3%) cases and 30(85.7%) controls were educated; 25(71.4%) cases and 20(57.1%) controls belonged to joint family; and 20(57.1%) cases and 17(48.6%) controls were from the middle socioeconomic class. Univariate logistic regression showed 15(42.8%) cases and 5(14.2%) controls were depressed (Table-1).



Multivariate logistic regression showed depression was significantly associated with cheek-biting (OR:4.52; 95% confidence interval [CI]:1.34-15.15) (Table-2).



Discussion

Oral mucosal lesions are a multi-factorial disease. Therefore, recognising the risk factors that promote this condition plays an important role in its management and prevention. Psychological stressors and depression may propagate its progression.¹⁵ The aim of the current study was to determine association between cheek-biting and depression in patients visiting dental clinics for routine check-ups. It found a strong association between cheekbiting and depressions, predominantly in females (60%) compared to males (40%). A case report of a 10-year-old boy who presented with multiple ulcerations over lower lip, showed the diagnosis of Major Depressive Disorder which was treated with anti-depressants and his condition improved.¹ Another study showed 82% of TMD patients had anxiety and 57% had depression.⁷ A research conducted on patients with temporomandibular disorders also showed 82% females as affected. According to the study, this could be due to the fact that women seek medical help early or due to psychological and hormonal factors pertaining to females.¹⁶ A survey at Polish university gave similar results showing significant number of women presenting with temporomandibular disorders and increased psycho-emotional activity and stress. The research concluded that people with emotional burden or easily excitable personalities suffered more from oral para-functions.¹⁷
In the current study, the ratio of educated patients with depression-related cheek-biting was 90% compared to uneducated patients which was only 10%. The ratio of stress-related cheek-biting among students, independents and housewives was 31.4%, 44.3%, 24.3% respectively. In a similar study, 58% students with TMD identified themselves as stressed.¹⁷ Common stressors could be low income, peer pressure, large number of duties, uncertain future or living away from family in a new environment. They also emphasised the fact that students are more exposed to social, emotional, physical and family problems.¹⁷With regard to marital status, it is indicated that 58.6% married patients are more prone to cheek-biting while only 41.4% unmarried were affected. Family system plays an important role in the contribution of stress related cheekbiting which is 64.3% while no family system is 35.7%. Other studies state that women who are widowed or married but living separately present more with oral problems compared to men.¹⁸ Socioeconomic status may be an influencing factor in this regard as individuals with low socioeconomic status 27.1%, middle class 52.9%, upper class 20% presented with cheek-biting. Social life of a person, as such, may be a stressor and can lead to oral problems. The current study excluded individuals with pregnancy and obesity because both the conditions have significant effects on the periodontal soft tissue. It enabled the study to control any bias. Prospective multi-centre studies must be conducted with large data sets, including patients of young age to the elderly. Other oral conditions like TMD, oral ulcers, lipbiting linked with stress can be added along with systemic conditions to draw up guidelines for a therapeutic approach to oral mutilation.

Conclusion

Depression and cheek-biting were found to be significantly associated. Psychological issues that may arise out of depression of everyday life Cheek-biting can cause cancerous growth over that region due to constant oral tissue mutilation. Early precaution in the cases of cheek-biting can increase the chances of survival.

Disclaimer: None.
Conflict of Interest: None.
Source of Funding: None.

References

1. Bhatia NK. Morsicatiobuccarum and labiorum with depression. Int J Dent Health Sci. 2015; 2: 1639-42.
2. Shamim T. The Psychosomatic Disorders Pertaining to Dental Practice with Revised Working Type Classification. Korean J Pain. 2014; 27: 16-22.
3. Saemundsson SR, Roberts MW. Oral self-injurious behavior in the developmentally disabled. Review and a case. ASDC J Dent Child. 1997;64:205-9.
4. Castellanos JL, Diaz-Guzman L. Lesions of the oral mucosa: An epidemiological study of 23785 Mexican patients. Oral Surg Oral Med Oral Pathol Oral RadiolEndod. 2008;105:79-85.
5. Slade GD, Diatchenko L, Bhalang K, Sigurdsson A, Fillingim RB, Belfer I. Influence of psychological factor on risk of temporomandibular disorders. J Dent Res. 2007; 86:1120-5. 6. Liao CH, Chang CS, Chang SN, Lyu SY, Morisky DE, Sung FC. The risk of temporomandibular disorder in patients with depression: a population-based cohort study. Community Dent Oral Epidemiol. 2011; 39:525-31.
7. Khotani AA, Akbar AN, Gjelset M, Albadawi E, Bello L, Magnusson BH, et al. The associations between psychosocial aspects and TMD-pain related aspects in children and adolescents. J Headache Pain. 2016; 17: 1-10.
8. Roda RP, Bagan JV, Sanchis JM, Carbonell E. Temporomandibular disorders. a case-control study. Med Oral Patol Oral Cir Bucal. 2012; 17: 794-800.
9. Vanderas AP, Papagiannoulis L. Multifactorial analysis of the aetiology of craniomandibular dysfunction in children. Int J Paediat Dent. 2002; 12:336-46.
10. Feteih RM. Signs and symptoms of temporomandibular disorders and oral parafunctions in urban Saudi arabian adolescents: a research report. Head Face. 2006; 2: 1-7.
11. Dean AG, Sullivan KM, Soe MM. OpenEpi: Open Source Epidemiological Statistics for Public Health: unmatched CC. [Online] 2013 [Cited2018 June 20]. Available from: URL: http://www.openepi.com/SampleSize/SSCC.htm.
12. Ali M, Joseph B, Sundaram D. Prevalence of oral mucosal lesions in patients of the Kuwait University Dental Center. Saudi Dent J. 2013; 25:111-8.
13. Dangore-Khasbage S, Khairkar PH, Degwekar SS, Bhowate RR, Bhake AS, Singh A, et al. Prevalence of oral mucosal disorders in institutionalized and non-institutionalized psychiatric patients: a study from AVBR Hospital in central India. J Oral Sci. 2012; 54:85-91.
14. Spitzer RL, Williams JBW, Kroenke K. Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (PRIME-MD PHQ): Urdu questionnaire. Columbia: Pfizer Inc. [Online] 1999
[Cited 2018 June 06]. Available from URL:
http://www. multiculturalmentalhealth.ca/wp-content/uploads/2013/11/PHQ-9-Urdu.pdf
15. Jaiswal R, Shenoy N, Thomas B. Evaluation of association between psychological stress and serum cortisol levels in patients with chronic periodontitis - Estimation of relationship between psychological stress and periodontal status. J Indian Soc Periodontol. 2016; 20:381-5.?”
16. Beitollahi JM, Mansourian A, Bozorgi Y, Farrokhnia T, Manavi A. Evaluating the most common etiologic factors in patients with TMDs: a case control study. J. Applied Sci. 2008; 8:4702-5.
17. Wieckiewicz M, Grychowska N, WojciechowskiK, Pelc A, Augustyniak M, Sleboda A, et al. Prevalence and Correlation between TMD Based on RDC/TMD Diagnoses, Oral Parafunctions and Psychoemotional Stress in Polish University Students. Biomed Res Int. 2014; 2014:1-6.
18. Mundt T, Mack F, Schwahn C, Bernhardt O, Kocher T, Biffar R. Association between sociodemographic, behavioral and medical conditions and signs of temporomandibular disorders across gender: Results of the study of health in Pomerania (SHIP-0). Int JProsthdont. 2008; 21:141-8.J Pak